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Chapter 38

### Key Points

1. Multiple techniques are in the surgeon's armamentarium for feeding access techniques in children.

2. Gastrostomy access can be achieved by a variety of technical approaches: Stamm or open gastrostomy, percutaneous endoscopic gastrostomy (PEG), laparoscopic-assisted gastrostomy, and radiologically assisted gastrostomy. The authors' preference is achieved by the visualization and inherent safety of the laparoscopic-assisted technique.

3. Gastrostomy morbidity can also be a significant feature of tube change.

4. The major morbidity of feeding enteral access tube placement relates to the need to exclude gastroesophageal reflux as a major clinical association. If present, feeding access may require a specific adjustment: gastrostomy with concomitant antireflux procedure, feeding jejunostomy being the most common alternatives available.

5. Gastrostomy remains one of the most common procedures done by pediatric surgeons.

### Introduction

Children who develop failure to thrive from a variety of clinical problems often require some type of long-term enteral access for feeds. Placement of a gastrostomy tube is indicated if oral nutrition is either not adequate or not feasible for a prolonged time interval. This can be due to an inability to swallow, inadequate caloric intake, unique feeding requirements resulting from metabolic disorders, or the practical requirement of the need for continuous enteral feeding. There are currently 5 different methods commonly used to obtain feeding access: (1) open gastrostomy (Stamm gastrostomy); (2) PEG; (3) laparoscopic gastrostomy; (4) percutaneous radiologic gastrostomy and percutaneous radiologic jejunostomy (PRG and PRJ); and (5) open jejunostomy. With the recent advances in minimally invasive treatment approaches, PEG and laparoscopic placement are now the most common techniques utilized in children. PRG and PRJ are performed by interventional radiologists and are becoming increasingly popular at centers where this service is available.

### History

The concept of gastrostomy was first described by Egeberg in 1837. Sedillot was the first to attempt to perform the procedure, initially in dogs in 1839, and then in humans in 1846. Unfortunately his efforts were unsuccessful and all 3 of the patients died. In 1876, Verneuil performed the first successful gastrostomy. Since that time a number of modifications have been developed, the most popular of which was described by Stamm in 1894. The Stamm gastrostomy involves a purse-string suture to invaginate the serosa of the stomach around a tube. Other developments include the PEG, first described by Gauderer in 1979, the PRG described by Preshaw in 1981, and most recently, laparoscopic gastrostomy as well as single incision laparoscopic gastrostomy.

### Indications

Many conditions are potential indications for placement of some type of feeding access, including neurologic impairment with developmental delay, aspiration problems resulting in pneumonia or other respiratory complications, or congenital anatomic anomalies such as esophageal atresia. All of these problems can potentially lead to failure to thrive and the need for supplemental enteral feeds. At other times, a gastrostomy is done to secure access to the esophagus for retrograde dilation management of a stricture.

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